403764_Well Construction - GW1_20120326

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1. WELL CONTRACTOR:
WILLIAM T. DUGGINS
Well Contractor (Individual) Name
TERRACON CONSULTANTS, INC
Well Contractor Company Name
5240 GREEN'S DAIRY ROAD
Street Address
RALEIGH
City or Town
(919 ) 873-2211
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 27605
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID Cif applicable) E1-2011-PZ-
3. WELL USE (Check One Box) Monitoring Cl Municipal/Public D
lndustriat/Commercial ❑ Agricultural 0 Recovery El Injection 0
Irrigation❑ Other CI (list use)
DATE DRILLED 1/bti20 1 2
4. WELL LOCATION:
EAGLE ISLAND
(Street Name, Numbers, Community, Subdivision. Lot No., Parcel, Z-Ip Code)
ciry:,WILMINGTON
TOPOGRAPHIC / LAND SETTING:
['Slope ❑Valley DFlat ❑Ridge
LATITUDE 36
LONGITUDE 75 °
TONRESJDENTII4L WELL CONSTRUCTION RECORD
-------�'�na Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTXFICATION # 3423
: d. TOP OF CASING IS 3 -1 FT. Above Land Surface*
n -7? - 4
*Top of casing terminated at/or below land surface may require
a vela -rice -in acco ance Witt iKNCAC 2C O118.
e. YIELD (gpm): N/A METHOD OF TEST NIA
f. DISINFECTION: Type N/A _ Amount N/A
g. WATER ZONES (depth)
: Top f i Bottom Z5 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
7. CASING:��Depth
Top' S Bottom "lc Ft.
: Top Bottom Ft.
: Top Bottom Ft.
'thickness/
DiameWeight Material
Pv
: 8. GROUT: Depth Material Method
: Top 0 Bottom 11) Ft. pC C Jr t° mid,
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth . Diameter Slot Size t ri
kri: Top t Bottom Ft. 2 in. (. in,
: Top Bottom Ft. in. In.
COUNTY NEW HANG; Top Bottom Ft. in. in.
(check appropriate box)
2i1 Other fig Vt k t� f
" DMS OR 3' .1?1,0 DD
,.DMSOR 7?.-,WO DD
Latitude/longitude source: 1ZGPS (]Topographic map
(location of well must be shown on a USGS topo map andaltached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Confined Ilisnosal Facility N/A
Facility Name
NLA
Street Address
EAGLE ISLAND
City or Town
Facility ID# (if applicable)
10. SAND/GRAVEL PACK:
• Depth Size Material
Top 0 , Bottom) Ft.
Top, Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom Formation Description
?,'a7 / Zc
/
1
I3en
onlact Na a CICif:6•
/
ii,v7 0VLU /
Mali g Ad ress ; /
WILMINGTON RC: /
City or Town State Zip Code
o) t 4V\c)
NO code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:
ZS�
NC
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES 0
c. WATER LEVEL Below Top of Casing:
(Use '+A if Above Top of Casing)
NO qf
FT.
12. REMARKS:
7,01
���
1ni°YR'�p�Nu��`+n9
I DO HEREBY CERTIFY THAT TI-CIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
: 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
RECORD HAS BEE PROVIDE ! T THE WELL OWNER.
3/12/12
SIGNAT F C ' TIRED WELL CONTRACTOR DATE
WILLIAM T. DUGGINS
• PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GIN-1 b
Rev. 2/09